Customer Name:________________________
Address:______________________________
_____________________________________
_____________________________________
Email:_________________________________

Contact:_________________
Phone:__________________

Ship:_______
Via:________

Wassco Corporation (Est. 1992)
515 S. 25th West Ave.
Tulsa, OK 74127
(918) 834-4444
(918) 832-8946 Fax

Fax Order to 918-832-8946

Qty	Product	Text	Each	Total
Qty	Silicon Wristbands
Qty	Tooling/Setup

Text:______________________________________________________________________

Qty: __________ Youth Color(s):_________________________________
Qty: __________ Adult Color(s):_________________________________

Inside Band Text (Add $100):________________________________

Qty	Product	Text	Each	Total
Qty	Silicon Wristbands
Qty	Tooling/Setup

Text:______________________________________________________________________

Qty: __________ Youth Color(s):_________________________________
Qty: __________ Adult Color(s):_________________________________

Inside Band Text (Add $100):________________________________

Payment Method

Amex Mastercard Discover Visa

Card #________________________________________________

Expiration Date:___________________

CVV:____________ (3 or 4 Digit Security # located on back of card)

Sub-Total:
Freight:
Total:
Amount Paid:
Amount Due: